LECTURES

Тhe article discusses the role of therapeutic collaboration (compliance) in the efficiency of a treatment process. It analyzes the relationship between the quality of compliance and psychological, clinical, therapeutic, social factors and specific features of medical care. There are data on the efficiency of current methods for optimizing therapeutic compliance. The quality of compliance in different diseases is discussed.

Recommendations are given to improve its quality in cardiovascular, chronic infectious diseases, cancers, skin, neurological, and mental diseases in children and elderly patients.

ORIGINAL INVESTIGATIONS

Brain injury (BI) is a major cause of cognitive impairments (CI) in young people. However, many aspects of their development remain unstudied. In particular, the role of neurodegenerative and vascular processes in the occurrence of posttraumatic disorders of higher cortical functions is still unclear. Voxel-based morphometry is one of the current neuroimaging techniques. Objective: to comprehensively study a change in the volume indicators of a number of brain structures in patients with posttraumatic, vascular, and amnestic CI.

Patients and methods. The investigation enrolled 123 patients who were divided into 5 groups: 1) 20 examinees without CI (a control group); 2) 22 patients with mild and moderate CI and a history of mild recurrent CI; 3) 19 patients with moderate posttraumatic CI after severe brain contusion; 4) 41 patients with moderate vascular CI; 5) 21 patients with moderate amnestic CI. Before divided into the groups, all the patients underwent comprehensive neuropsychological testing, which enabled different aspects of cognitive performance to be assessed.

Results. Atrophic changes were ascertained to be uncharacteristic for the patients who had sustained mild recurrent BI. At the same time, the patients with severe consequences of BI showed a significant decrease in the volume of brain regions, primarily in that of frontal and temporal lobes. A combined comprehensive assessment of the results obtained in the group analysis using SPM8 and calculating absolute volume values using MRICroN allowed one to more accurately understand the nature of neurodegenerative changes. Comparative assessment of the data obtained in the posttraumatic, vascular, and amnestic CI groups identified a number of differences in both the distribution of atrophic changes and their level, which can be of great importance for the differential diagnosis of these conditions.

Objective: to study the efficiency of treating neurasthenia by psychotherapy in combination with reflexotherapy (acupuncture) and phytotherapy.

Patients and methods. Psychotherapy or combination treatment (psychotherapy + reflexotherapy, psychotherapy + phytotherapy) was performed in 96 neurasthenic patients (65 men and 31 women) aged 18 to 40 years. Therapeutic effectiveness was evaluated by psychometric testing using the Clinical Global Impression Scale (CGI), the Spielberger-Hanin test, and the multidimensional fatigue inventory (MFI-20).

Results. All the patients underwent a complete treatment cycle for 35 days. After the therapy, all the patients showed a stable reduction in emotional lability and a decrease in the magnitude of somatic complaints. Analysis of CGI data revealed the good therapeutic effect of a combination of non-drug treatments: at the initial stage of therapy, it was rated as improvement; by the end of the third week, a noticeable improvement was recorded in half of all the patients. According to the clinical assessment, practical recovery and considerable improvement were noted in 60.8% of the patients in Group 1, in 69.7% in Group 2, in 37% in Group 3, or in 57.3 of all the patients. The MFI-20 scores for all sections improved significantly. The mean Spielberger-Hanin scores for personal and reactive anxiety decreased from 34.5 to 29.5 and from 35.5 to 32.1, respectively.

Conclusion. The combination treatment of neurasthenia was established to be highly effective. A combination of psychotherapy and phytotherapy was more effective for comorbidity of asthenic symptomatology with anxiety and depressive manifestations, so was that of reflexotherapy and psychotherapy for somatoautonomic disorders and an anxious component. Psychotherapy as monotherapy proved to be less efficient.

Objective: to assess restorative and compensatory mechanisms in victims of blast injury (BI) in its late period.

Patients and methods. A clinical and neurophysiological examination was made in 78 blast victims, among whom there were 75 men and 3 women at the age of 30 to 48 years (mean age 37.4±3.2 years). The patients were divided into two groups: 1) 51 (65.4%) patients with BI concurrent with varying degrees of brain injury and concomitant complications; 2) 27 (34.6%) patients with BI and mainly peripheral involvement (limb amputation). Most (84%) victims were 20–40 years old. A control group consisted of 27 ageand gender-matched healthy individuals. The trend in BI sequels was traced within 3 years after injury. Cardiointervalography was employed to evaluate autonomic tone.

Results. Varying degrees of adaptive processes were found in the groups under study; the neurophysiological price of traumatic impact of BI on the regulation of adaptive mechanisms in its late period was mathematically expressed. The most favorable adaptation according to autonomic support parameters and its stabilization were noted in Group 2 victims. These patients had long an autonomic imbalance with sympathetic dominance. An orthostatic test could reveal autonomic responsiveness in both groups, pointing to the breakdown of central regulatory mechanisms with emphasis to trophotropic parasympathetic dominance in the compensatory and restorative processes of autonomic support.

The paper describes the impact of migraine information-educational programs on clinical parameters, quality of life, subjective treatment satisfaction, and financial aspects associated with headache (the burden of migraine). A combination of resident and non-resident migraine health educational programs has been found to have advantage. The programs used in this investigation could lower the duration of attacks and the intensity of headache according to the visual analog scale, reduce the use of analgesics, and improve patient satisfaction with treatment.

The implementation of the educational programs is ascertained to reduce disability days. There is a need to repeat training courses.

The results of treatment have been found to be related to what leverages are used in the program.

REVIEWS

The capabilities of antithrombotic therapy to prevent thromboembolic events in nonvalvular atrial fibrillation (AF) are substantially extended after designing and clinically introducing new oral anticoagulants, one of which is dabigatran. A wealth of world clinical experience with dabigatran has confirmed its efficacy and safety provided that all recommendations for dosage regimens are followed. The universal properties of the drug can hope that the indications for its use will be extended and will not be confined to the prevention and treatment of venous and atrial thromboses and thromboembolisms. Whether dabigatran may be used in acute myocardial infarction and coronary stenting in the presence of nonvalvular AF, left ventricular thrombosis, and cardiomyopathies is being considered today.

The paper gives summarized data on vascular encephalopathy (VE) and vascular cognitive impairments (CI). The pattern of intellectual and amnestic disorders in cerebrovascular disease and methods for their assessment are presented. Investigations of the prevention and drug therapy for this abnormality are detailed. Particular emphasis is laid on vasoactive therapy and the use of vinpocetine; the largest Russian clinical and clinicoexperimental investigations performed in recent years are analyzed. Correction of vascular risk factors, arterial hypertension in particular, is shown to be of importance. The data available in the literature on the possible use of vinpocetine on poststroke day 5 are given. The basic principles of therapy for CI in VE are stated.

Postherpetic neuralgia (PHN) is one of the most common and persistent chronic pain syndromes caused by chickenpox virus affecting the peripheral and central nervous systems. PHN is a typical neuropathic pain resulting from injury or dysfunction of the somatosensory system whose development involves a few mechanisms. Elderly people are more prone to PHN, which is associated with the weakened immune system. Treatment of shingles cannot completely prevent subsequent neuralgia; however, some drugs can reduce its manifestations. The diagnosis of PHN is largely based on the duration of pain after rash onset. However, it is difficult to estimate the real rate of PHN development because there is neither consensus of opinion on this issue nor common criteria for pat duration (1 to 6 months, as shown by different data). The significant factors that may predispose to PHN are older age, female gender, and acute herpes zoster indicators, such as pain intensity, the severity of herpetic rash and infectious manifestations. Pain syndrome in PHN can reach a high intensity level, accompanied by the development of chronic fatigue, depression, and loss of social skills. There are several types of pain in PHN: constant, paroxysmal and allodynia, which are due to different pathophysiological mechanisms. Variability in the clinical manifestations of PHN may underlie the inadequate efficacy of one or other drug. The treatment of PHN poses definite difficulties. About 40-50% of patients continue to suffer from pain despite the fact that the multitude of currently available therapies is performed. Pregabalin, whose high efficacy and advantages in the treatment of pain in PHN are demonstrated in numerous studies, is one of the most effective first-line drugs for PHN. In-depth analysis suggests that inadequately low doses of pregabalin are frequently used in the treatment of PHN, which may lead to an insufficient analgesic effect.

The paper shows the relevance of the problem associated with the diagnosis and treatment of stroke in young patients aged 15-45 years. It considers the major causes of acute cerebrovascular accidents in young people, including pregnant women. Diseases, such patent foramen ovale, mitral valve prolapse, infective endocarditis, and postpartum cardiomyopathy, are described in detail. The basic principles of the diagnosis and therapy of ischemic stroke at a young age are given. The mainstay of therapy for acute ischemic stroke is stated to include two procedures: reperfusion and neuronal protection.

The rate of posttraumatic stress disorder (PTSD) averages 23% within the first year after stroke and 11% in succeeding years. Its risk is particularly high following subarachnoid hemorrhage or restroke in young patients and in patents with a history of mental illness. PTSD decreases quality of life in patients after stroke and their adherence to drugs for the secondary prevention of vascular diseases. PTSD patients are predisposed to post-stroke depressive disorders. PTSD treatment after stroke involves medication and psychotherapy.

Musculoskeletal pain syndromes are one of the most common causes of disability and referral to a medical specialist. Seven million consultations for lumbosacral pain are annually carried out in the United Kingdom.

Examination of patients with back pain. Three levels of health care delivered to patients with back pain in the United Kingdom may be arbitrarily identified. Level 1 is outpatient: a general practitioner jointly with a manipulative therapist, a physiotherapist, a rehabilitation specialist, and mid-level health workers render care to patients with insignificant and mild pain syndrome; Level 2 is also outpatient, which involves the participation of a hospital or multidisciplinary team consultant, for example, in a musculoskeletal pain service or a specialized pain center; Level 3 is to deliver care at neurosurgical or orthopedic hospital, by applying invasive interventions. Acute back pain is a benign condition in the vast majority of cases; there is no need for additional instrumental and laboratory studies; but spinal X-ray study, computed tomography (СT scan), or magnetic resonance imaging (MRI), general blood and urine tests are required when marked neurological and somatic disorders are present.

Management of patients with acute lumbosacral pain is to inform a patient about the benign nature of the disease; to exclude bed rest; to explain the need to maintain normal activity; to train how to correctly lift weights and to maintain normal posture; to refer for manual and exercise therapy in order to return to normal motor activity; to use proven effective medication. In most cases, acute back pain goes away spontaneously for a short period of time; an active treatment approach is considered to be optimal. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are used for analgesia if required. Patients who show no improvement after 4 weeks of treatment need rescreening for markers of potentially dangerous spinal diseases, as well as determination of the signs of psychosocial ill-being and correction of therapy with consideration for identified disorders.

Management of patients with subacute and chronic pain (persisting for >6 weeks, but <1 year) involves the regular reconsideration of whether the diagnosis of nonspecific back pain is correct in order to rule out possible specific causes. MRI is indicated when a patient is decided to be referred for surgical treatment or there is presumptive evidence for spinal tumors, infectious, inflammatory, or traumatic injury, or cauda equina syndrome. It is optimal to start treatment with a program of therapeutic exercises, manual therapy, or acupuncture. Drug therapy encompasses NSAIDs, acetaminophen, and opioids to treat intensive pain syndrome.

To manage patients with low back pain is an urgent problem of modern medicine. The paper covers the main causes of chronic nonspecific lumbago and the principles of its diagnosis and treatment in the context of evidence-based medicine. A multidisciplinary treatment approach involving drug therapy with analgesics (nonsteroidal anti-inflammatory drugs), antidepressants, myorelaxants, therapeutic exercises, and cognitive-behavioral therapy is noted to be highly effective.

The literature review deals with the use of glucocorticoids (GC) for nonspecific vertebrogenic pain and radiculopathy. The pathophysiology of radiculopathy and the role of mechanical and chemical components in the development of pain syndrome are discussed. The data of clinical trials analyzing the efficiency of epidural GC use, as well as possible indications for this therapy and its adverse reactions are under consideration. The available concepts of the analgesic effect of epidural CG are discussed.

Pain syndromes in the neck and head regions are one of the most difficult conditions to be interpreted in clinical practice. Craniocervical anatomical and physiological features are a basis for development of mixed pain syndromes showing as a polymorphic clinical picture in the presence of not only painful, but also tonic muscle, autonomic, postural, vestibular, and other disorders. The current concept of cervicocranialgia is based on the views and convergence between cranial (trigeminal) and upper cervical afferents, as supported by clinical and experimental data. These mechanisms are responsible for referred pain phenomena that are so characteristic of myofascial pain syndromes in the neck, head, and face. Myofascial pain may both be independent and occur in other types of primary headaches, specifically in migraine and tension headache. In these cases, the clinical symptomatology takes the features that are highly characteristic of myofascial pain: referred pain with a typical pattern of its spread, as well as trigger points and pain associated with postural loads and other physical factors. These peculiarities should be kept in mind when diagnosing pain syndromes in the craniocervical region. Current approaches to managing patients with cervicocranialgias encompass relief of pain and tonic muscle disorders and compensation for postural disturbances. For this, it is customary to use pharmacotherapy with antidepressants, nonsteroidal anti-inflammatory drugs, and myorelaxants. Effective analgesia in these patients still remains an unsolved problem. Analysis of clinical trials can identify the most effective analgesic and safe agents for pharmacotherapy. The phenomena of myofascial pain determine the expediency of using myorelaxants that exert an intrinsic analgesic effect and reduce tonic muscle phenomena.

The novel «Bratya Karamazovy» by F.M. Dostoevsky presents a whole series of literary characters whose neuropsychiatric health cannot be considered to be impeccable. Various clinical conditions, such as neurasthenia, mental retardation, epilepsy, obsessive-compulsive and conversion-and-dissociative syndromes, may be retrospectively recognized with varying degrees of credibility and validity in many characters of the novel. In terms of belletristic literature, the description of their behavior and external manifestations is notable for brilliance, richness of content, surprising clinical accuracy, and scrupulosity.

The practical introduction of the latest genetic techniques could provide the basis for comorbidity of genetic epilepsies and behavioral disorders with cognitive impairments. This article describes a case of SNGAP1 mutation in an 8-year-old female patient having symptomatic epilepsy with epileptic eyelid myoclonia and atypical absences, atypical autism with mental retardation. A detailed clinical discussion deals with neurological and mental states, logopedic characteristics, and psychological examination findings, as well as video-EEG monitoring data.

Dementias are much more rarely encountered in young than in older people. However, the highest percentage of dementias is reversible in young patients. The diagnosis of cognitive impairments in this patient category makes it possible to identify the underlying disease and to perform adequate therapy at their early stage. The clinical features of dementias that are most common at a young age and the possibilities of their early diagnosis are covered. The authors describe their own clinical observations in patients with neuroAIDS, Huntington’s disease, or multiple sclerosis.

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